July 2014

TransplantLaboratory Tests for Heart Transplant Rejection
The use of peripheral blood genetic profiling tests in the management of patients after heart transplantation, including but not limited to the detection of acute heart transplant rejection or heart transplant graft dysfunction, is considered investigational and not covered.

Electrical/Neuromuscular StimulatorPelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
No coverage will be provided for electrical or magnetic stimulation of the pelvic floor muscles (pelvic floor stimulation) as a treatment for fecal incontinence as this is considered investigational.

Sacral Nerve Neuromodulation/Stimulation
A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessaryand coveredin patients who meet all of the following criteria:

Percutaneous Kyphoplasty, Vertebroplasty and SacroplastyPercutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation
No coverage will be provided for percutaneous mechanical vertebral augmentation using any other device, including but not limited to Kiva® VCF Treatment System, and vertebral body stenting as this is considered investigational.

Use of Common Genetic Variants (SNPs) to Predict Risk of Nonfamilial Breast CancerUse of Common Genetic Variants (SNPs) to Predict Risk of Nonfamilial Breast Cancer
Testing for one or more single nucleotide polymorphisms (SNPs) to predict an individual’s risk of breast cancer is considered not medically necessary and not covered.

The OncoVue® and BREVAGen™ breast cancer risk tests are considered investigationaland not coveredfor all indications, including but not limited to use as a method of estimating individual patient risk for developing breast cancer.

Serum Biomarker Tests for Multiple SclerosisSerum Biomarker Tests for Multiple Sclerosis
No coverage will be provided for serum biomarker tests for multiple sclerosis as they are considered investigationalin all situations.

Vectra® DA Blood Test for Rheumatoid ArthritisVectra® DA Blood Test for Rheumatoid Arthritis
No coverage will be provided for the use of a multi-biomarker disease activity score for rheumatoid arthritis (RA) (eg., Vectra DA score) as this is considered investigationalin all situations.